Case #463

Introduction of Primary Care in the Swedish NorDRG system for 2017

Added by Anonymous almost 4 years ago. Updated about 3 years ago.

Status:AcceptedStart date:2016-02-02
Priority:MajorSpent time:-
Assignee:Ralph Dahlgren
Category:-
Target version:Expert Group 2016
Initiator:Sweden Target year:2017
Case type:Major Owner / responsible:National organisations
MDC: Old forum status:
Target Grouper:SWE

Description

Problem
This is for information, short, to describe the Swedish Primary Care that is going to be introduced to the Swedish NordDRG system for 2017.
Does not concern any other country but everyone is given the possibility to use if wanted to.

The Swedish Government gave an assignment to the The National Board of Health and Welfare, Sweden:
To Develop compensation in health care 2008 – 2010.
National Board interim report consisted of “An inventory of the various secondary patient classification systems in primary care". It also made a summary of criteria for how a describing systems in primary care should be designed. Some of these criteria follows below and also slightly modified:
Minimum level of grouping; health care contact in the form of visits to independent care providers
Information indicating the medical care carried out
Clinically relevant groups
Describes care services instead of individual actions
Based on common definitions
Based on established classifications used, ICD-10 SE and KVÅ
Based on medical ground information, the information retrieved from the journal
The classification system should include as much as possible cases and also show flexibility, all patients must be described and grouped in the classification system.
Neutral regardless of caregivers
The classification to be used at various levels, both nationally and locally
The system must at some level be linked to NordDRG system (type MDC). Monitoring and evaluation of health services in both inpatient and outpatient care with the common link provides valuable information about health care consumption.
The system should be transparent "no black box."
The logic of the classification system shall be documented and available to users.

Part of the "Project to investigate the conditions for the development of the described system for primary care started 2013-11-18 at a meeting with multiple representatives from different Swedish Health counties.
The conclusion was that there was a need for a national secondary description system for primary care that meets the requirements, and in a general way gives a description of what care the Primary care providers produce.

Two main paths was drawn:
Entrance through the NordDRG Description system for primary care The Finnish pDRG system as a model for description for primary care.
The decision was made to go through NordDRG when the Finnish system was not transparent and moreover cannot be integrated in current NordDRG.

During the process there was a possibility to get Primary care data from Health Care Providers.
It turned out that about 80 percent of the data were grouped into regular outpatient DRG.
The Primary care data was also grouped with inpatient logic for NordDRG 2015 and it showed that the material was of such quality that it also grouped into different CC levels. In certain DRGs, there was a major outcome of DRG with CC levels rather than DRG without CC. This suggests that in these DRGs are the patients that are included in what in Sweden is called “multiple illnesses patient”. Going through the outcome manually it turned out that the involved DRG are such that they often have patients with multiple diseases.

It was decided that there should be made an extension of the present outpatient DRG groups so that more DRG should have "complicated" level as an expression to include the multiple illnesses patient and also that some other types of patients always are more time consuming (this fact is already present in the regular NordDRG system).
It was decided that a few more diagnoses always should complicate a visit, this on top of the diagnoses that already has CC-levels in the current NordDRG.
It was also decided to expand the Primary care DRG-system with groups for “Electronic-health, Home visits and Long-term care.

A clinical review of all Outpatients DRG in NordDRG 2015 was done. The DRG which only contained visits that is impossible in Primary care was erased. Some in care-patient DRG was included.
A review and an overview of those DRG with great numbers of visits was done, comparing it with the outcome of grouping of the same material with the in care DRGlogic showed a great outcome on two levels, not complicated - complicated. An additional splitting of some DRG was done for age, giving a better description of the patient visits. Some DRG was divided to give a better medical description due to the fact that different age groups in Primary care differs in diseases.

Analysis
The National Board of Health and Welfare, Sweden – 2015-01-15
Primary Care data has been grouped with the Swedish NordDRG definition tables, both with the logic for Outpatient DRG and for in patient DRG. Showing that the Swedish Primary Care have a quality of primary coding that makes it possible to statistically see that they will have no problem doing the coding to get the developed “Primary Care DRGlogic” work. That includes a non-CC level and a CC-level for their visits.
The group has not had any cost data to look at. The Swedish 24 different counties have each and everyone different reimbursement systems.
This means that the Swedish Primary Care DRG system is made out from a statistical and medical perspective.

Suggestion
The National Board of Health and Welfare, Sweden – 2015-01-15
Sweden wants the Primary care to be included in our Swedish NordDRG system for 2017. Sweden is well aware of the fact that no other of the collaborating countries will start using this system, this due among other things to the fact that Primary care in different countries coded differently.

Decided changes
The National Board of Health and Welfare, Sweden – 2015-01-15
Sweden wants the Primary care to be included in our Swedish NordDRG system for 2017.

Technical change
Most of the Primary Care DRG are already existing in the Swedish DRGlogic for out care patients. Some more DRG has been invented. A lot of the DRG have two levels, non-CC and CC.
To be able to be grouped with the Primary care DRGlogic the Swedish Procedure code ZV050 Primärvård with a new DGPROP 99X50 Primärvård has to be used. Every row in the Primary Care DRGlogic demands a DGPROP 99X50.
The DRG for Seizures and headaches - Divided into one DRG for cramps and one DRG for headache and migraine.
The DRG for Infections of the upper respiratory tract and ear - Divided into one DRG for infections of the upper airways,> 17 years, one DRG for infections of the upper airwais, 0-17 years. One DRG for infections of the ear,> 17 years, one DRG for infections of the ear, 0-17 years.
The DRG for Other diseases of the ear, nose, mouth and throat,> 17 years - Divided into one DRG for ear diseases,> 17 years, one DRG of the diseases of the nose, mouth and throat,> 17 years.
The DRG for Other diseases of the ear, nose, mouth and throat, 0-17 years - Divided into one DRG for Ear diseases, 0-17 years, one DRG for diseases of the nose, mouth o throat, 0-17.
The DRG for Abdominal pain and gastroenteritis,> 17 years - Divided into one DRG for abdominal pain,> 17 years, one DRG for gastroenteritis ,> 17 years.
The DRG for Abdominal pain and gastroenteritis, 0-17 years - Divided into one DRG for abdominal pain, 0-17years, one DRG for gastroenteritis 0-17 years.
The DRG for Virus Infections - Divided into one DRG for Flu, one DRG for Cold and one DRG for Other viral infections.
Nurse visits are divided into new groups:
• Nursing Visit diabetes, primary care
• Nursing Visit BVC (Small Children Care), primary care
• Nursing Visit immunization, primary care
• Nursing Visits blood pressure control, primary care
• Nursing Visit telephone, primary care
• Nursing Visit COPD / asthma, primary care

New DRG groups for Primary Care
• In-depth pharmaceutical review of patients medication
• Targeted health check
• Visit with unplanned enrollment to in care
• Virtual contacts – group of patients for other media contacts than phone
• Groups for home visits - one group per MDC
• Inpatients (occurring in rural areas) - one group per MDC

Some types of contacts will always be grouped in Primary care to complicated DRG:
• Multiple diseases - will have an impact through the use of existing NordDRGs grouping characteristics but with the addition of some additional ICD10-SE diagnoses receiving CC only in Primary care context.
• Interpreter Participation – Procedure code for interpreter given CC capacity, is making an impact in all DRGs that have complicated level.
• Reduced autonomy of both physical and neurological - Available for the most part already in current NordDRG but extended with some additional ICD10-SE diagnoses receiving CC only in Primary care context.

Total 872 ICD 10 codes will get the addition of new DRPOP.
A total of 23 procedure codes get the addition of new DGPROP.
These additions will allow the involved codes to be grouped into the new DRG created for primary care.

Technical changes are included in the file “Decision C628 Technical changes for Swedish Primary care”

Decision C628 Technical changes for Swedish Primary care Updated 20160202.xlsx (175 KB) Anonymous, 2016-02-03 17:12

Drglogic#463.csv Magnifier (94.8 KB) Martti Virtanen, 2016-03-29 11:30

DG1#463.csv Magnifier (88.6 KB) Martti Virtanen, 2016-03-29 11:30

Proc#463.csv Magnifier (88.6 KB) Martti Virtanen, 2016-03-29 11:30

Dgprop#463.csv Magnifier (1.12 KB) Martti Virtanen, 2016-03-29 11:30

DRGnames#463.csv Magnifier (51.5 KB) Martti Virtanen, 2016-03-29 11:30

#463 updated technical changes 20160412.xlsx (183 KB) Ralph Dahlgren, 2016-04-12 13:03

Technical changes #463 updated 2016-05-16.xlsx (172 KB) Martti Virtanen, 2016-05-24 17:32

#463 updated technical changes 20160608.xlsx (183 KB) Mats Fernström, 2016-06-08 16:27

Technical changes case #463.xlsx (260 KB) Martti Virtanen, 2016-06-22 12:16

Technical changes #463, errors corrected 20160818.xlsx (15.9 KB) Ralph Dahlgren, 2016-08-18 14:15

History

#1 Updated by Anonymous almost 4 years ago

  • File deleted (Decision C628 Technical changes for Swedish Primary care.xlsx)

#2 Updated by Anonymous almost 4 years ago

From Ralph Dahlgren´s requet the attachement has been changed to a corrected version.

#3 Updated by Martti Virtanen over 3 years ago

2016-03-09 Nordcase - Martti Virtanen
This Swedish model for primary care grouping is based single contact model that in general does not describe the activity of primary care very well. The incentive is to create as many contacts as possible for best possible economic result. This problem exists also in current secondary care NordDRG but it is probably even less favorable in primary care.
The difference to secondary care is based on registration of one code ZV050 'Primary care'. Omitting that code will obviously increase the reimbursement. In most situations currently, this is not a problem, since certain units only produce primary care.
However, the system is not applicable for example in Finland where the plan is to combine the organizations from primary and secondary care (and including even welfare units). Already now the on call activity is mostly combined and this arrangement is not applicable in those situations.

However, technically this is not a problem, we can create the rules according to the proposal. Since we should work towards a common model, I would propose that the ord-codes would start wiht '*' instead of zero. Then the current group '0' ord-codes would not need to be changed.

I wonder, is it actually necessary to have different error codes in primary care and secondary care? Missing dx is missing dx anyway!?

#4 Updated by Martti Virtanen over 3 years ago

2016-03-15 Expert group (MV)
Expert group accepted the proposal. The primary care version is implemented to NordDRG SWE 2017 version.
As discussed at the meeting the changing of the existing rules will create unnecessary work and make comparisons between the different version more difficult. To ease the comparisons two changes have been made to the Swedish proposal in technical changes document:
1) Ord-codes of the primary care rules start with '_' (instead of '0'). The third letter is still 'D' instead 'B'. This makes the changes to the ord-values of existing rules unnecessary.
2) The indicator of primary care contact DgProp='99X50' is for all primary care rules Dgprop1. The other diagnosis properties needed in the grouping are placed to DgProp2-4.
These changes obvious do not affect the DRG assignment of the new system.
It gives a possibility to develop other primary care groupings to other version of NordDRG within the same ordering coding
It also gives much more space for future development of the primary care system.
'
' is in the ASCII set before all numbers which results in correct ordering of the rules when sorted by Ord-values
The table will be copied directly to the SWE version Drglogic. For that purpose the file is transformed to text (CSV) format.

#5 Updated by Ralph Dahlgren over 3 years ago

As mentioned above the meeting accepted the original proposal. Martti then made some changes both to the ord value and also in the DRGlogic table.
Sweden has discussed Martti´s suggestion and also looked at the technical changes.
1. The ord values in DRGlogic table – Sweden wants the ord values in the DRGlogic tableto be kept as in the primary suggestion. This means that the ord values for Swedish Primary care will start with “000Bxxxxxx”. This means unlike what was discussed at the Expert group meeting the 14-15 march that the Swedish rows will be staying before all other rows for every country but due to ASCII international rules no other country will have to have their ord values changed. They can stay as they are right now. If other countries wants to add something else before todays rows they can use “000Axxxxxx” or “000Cxxxxxx”. If even more needs to be added everyone can change todays “000Dxxxxxx” to “000Nxxxxxx”, this making it possible to use all the letters between E to M aswell.
2. Martti´s technical changes for the DRGlogic table contained another change, the grouping property for procedure code ZV050 'Primary care' DGPROP 99X50 was moved from the original place. Martti added as this DGPROP as the first property in all the Primary care rows. Sweden accepts this change even if this wasn´t in the original proposal.

3. Martti added for ord 000B000040 DRG Z71R Huvuddiagnos ogiltig, primärvård in the column for PROCPRO 1 ”99V35” which is correct.
To ease the work for the Nordic CaseMixCentre Sweden has completed the technical changes decided above.
Sweden add to this case the file #463 updated technical changes 20160412.

#6 Updated by Martti Virtanen over 3 years ago

  • File Technical changes #463 updated 2016-05-16.xlsx added

2016-05-16 NCC Martti Virtanen

After several discussions with Sweden Socialstyrelsen has accepted a model that we hope will serve the needs of all participants. The process has taken quite some time because of several urgent matters.
We agreed that the the first character of the ORD-code must indicate the order of main groups, in this case the primary care. It was agreed that it will be '#'that is most likely not to cause any other problems. '-', '+' and '*' are used for different specific purposes and should be avoided. '_' is not at correct place in the ASCII system.
In addition we needed to define a common DRG-code in addition to the local Swedish code that was given by Sweden. Since this a totally new area of NordDRG and since the old system is very crowded I have chosen to use the Swedish coding as such. I.e. for these DRG's we will follow the Swedish coding as the common DRG coding also.
One line was removed because of the changes in case #376.
The technical changes document is updated with these changes.

#7 Updated by Martti Virtanen over 3 years ago

  • File deleted (Technical changes #463.xlsx)

#8 Updated by Mats Fernström over 3 years ago

Mats Fernström, NPK, Sweden, 2016-05-18
The file "Technical changes #463 updated 2016-05-16.xlsx" is still not the right one.

#9 Updated by Martti Virtanen over 3 years ago

  • File Technical changes #463 updated 2016-05-16.xlsx added

2015-29-5 Martti Virtanen
Sorry for the typo.

#10 Updated by Martti Virtanen over 3 years ago

  • File deleted (Technical changes #463 updated 2016-05-16.xlsx)

#11 Updated by Martti Virtanen over 3 years ago

2016-05-24 Martti Virtanen
I found one further error. The DRGnames has DRG R70R which does not exist in the logic. There is the DRG R70L that does not exist in the DRGnames. The correct DRG seems to be R70L and the DRGnames is now corrected accordingly.

#12 Updated by Martti Virtanen over 3 years ago

  • File deleted (Technical changes #463 updated 2016-05-16.xlsx)

#13 Updated by Mats Fernström over 3 years ago

2016-06-08. Mats Fernström, NPK, Sweden.
There is a small but significant error in the "Technical changes". The properties 50X14 and 50X16 have been reversed in the table "Drglogic". This has been fixed in the attached file (#463 updated technical changes 20160608.xlsx) where the properties 50X14 and 50X16 also have the correct texts in the table "Dgprop".

#15 Updated by Martti Virtanen over 3 years ago

2016-06-21 Nordic Casemix Centre (MV)
The case had a major prblem, because the mappings of the the codes that need new properties was never checked. The properties got to be given to a large number of codes that was not intended.
In the future it is important that also the national changes include a checkup of the mappings.
The new technical changes document covers thsi problem.

#16 Updated by Martti Virtanen over 3 years ago

  • File Technical changes case #463.xlsx added

#17 Updated by Martti Virtanen over 3 years ago

  • File deleted (Technical changes case #463.xlsx)

#18 Updated by Martti Virtanen over 3 years ago

2016-06-22 MV
Ordering errors in the Technical changes table for NCSP+ new.

#19 Updated by Ralph Dahlgren over 3 years ago

Technical updates due to the fact that Liselotte Säll discovered some obvious errors that must be corrected before the Swedish Countys start using the Swedish Primary Care in NordDRG.

#20 Updated by Ralph Dahlgren over 3 years ago

  • File Technical changes #463, errors corrected 20160818.xlsx added

#22 Updated by Ralph Dahlgren over 3 years ago

  • File deleted (Technical changes #463, errors corrected 20160818.xlsx)

#23 Updated by Anonymous about 3 years ago

  • Status changed from Active to Accepted

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